Acute retinal necrosis and ocular neovascularization caused by cytomegalovirus following intravitreal dexamethasone implant (Ozurdex® ) in an immunocompetent patient

Cytomegalovirus Retinitis Associated With Intravitreal Dexamethasone Implant Injection

Purpose: To describe an immunocompetent patient with cytomegalovirus (CMV) retinitis after dexamethasone implant injection and review previously documented cases. Methods: A review of case reports and literature was performed. Results: A 75-year-old man presented with acute decreased vision in the left eye. He had a vitrectomy and membrane peeling for an epiretinal membrane with recurrent cystoid macular edema and was receiving intravitreal dexamethasone implant injections at an outside hospital. The visual acuity in the left eye was hand motions, and an examination found patchy retinal whitening with hemorrhages. Aqueous polymerase chain reaction was positive for CMV. The laboratory evaluation was negative for immunodeficiencies. He was treated successfully with intravitreal and oral antivirals; however, his vision remained poor at most recent follow-up. A literature review found 8 previous cases of CMV retinitis after dexamethasone implant injection, although most had underlying immune dysregulation. Conclusions: CMV retinitis after intravitreal dexamethasone implant injection is rare. Awareness of this complication is essential because of the risk for devastating blindness.

Intravitreal dexamethasone implants facilitate the management of refractory Behçet's uveitis with vasculitis

To investigate the efficacy and safety of dexamethasone (DEX) implant, Ozurdex ®, as an adjunctive treatment for refractory Behçet's uveitis (BU), a total of 61 patients (80 eyes) were included in this cross-sectional study and divided into the non-DEX and DEX groups. After >12 months of treatment, the improvement in the fluorescein angiography score and vitritis score was significantly higher in the DEX group than in the non-DEX group. Although the posterior capsule opacification score was exacerbated, the rate of low-dose systemic glucocorticoid was higher and the relapse times were fewer in the DEX group. Therefore, Ozurdex® is an effective and safe option for patients with BU that are refractory to systemic immunosuppressant treatments by controlling vasculitis, stabilizing vitreous inflammation, preventing recurrence, and reducing daily glucocorticoid doses.

Toxoplasma Retinochoroiditis Following Intravitreal Dexamethasone Implant Injection for Diabetic Macular Edema: A Rare Complication

PURPOSE

To report a case of ocular toxoplasmosis as a rare complication of intravitreal dexamethasone implant in a case of diabetic macular edema.

METHODS

A 56 years old male, a known case of Proliferative Diabetic Retinopathy, received intravitreal dexamethasone implant for diabetic macular edema in left eye. He developed toxoplasma retinochoroiditis involving the macula with further diminution of vision in his left eye 3 weeks after the injection. His serum titres were positive for Toxoplasma IgG (161 IU/ml). He was treated with oral Sulfamethoxazole 800 mg + Trimethoprim 160 mg 12 hourly for 4 weeks.

RESULTS

The visual acuity in left eye improved with resolution of retinochoroiditis after the course of antibiotic therapy.

CONCLUSION

It is imperative to follow-up closely after intravitreal steroid implantation, to look for the possible rare complication of infectious retinitis/retinochoroiditis, as timely antimicrobial treatment can lead to a good visual outcome.

NEOVASCULAR COMPLICATIONS FROM CYTOMEGALOVIRUS NECROTIZING RETINOPATHY IN PATIENTS AFTER HAPLOIDENTICAL HEMATOPOIETIC STEM CELL TRANSPLANTATION

PURPOSE

To report the incidence and clinical features of neovascular complications from cytomegalovirus (CMV) necrotizing retinopathy in patients after haploidentical hematopoietic stem cell transplantation.

METHODS

Thirty-nine patients (58 eyes) of CMV necrotizing retinopathy after haploidentical hematopoietic stem cell transplantation in our institute between January 2018 and June 2020 were retrospectively reviewed, and cases that developed neovascular complications during follow-up were identified and described.

RESULTS

Two (2 eyes) cases that developed neovascular glaucoma from CMV necrotizing retinopathy were identified. Both of them manifested as granular peripheral retinitis, panretinal occlusive vasculitis, and some degree of intraocular inflammation, which were consistent with chronic retinal necrosis. Insidious progression of isolated immune-mediated occlusive vasculitis that could only be observed on fundus fluorescein angiography without active retinitis or intraocular inflammation was recognized to be the cause in one of two cases.

CONCLUSION

Neovascular glaucoma developed in 5.1%/cases and 3.4%/eyes complicated by CMV chronic retinal necrosis and vasculitis in patients after haploidentical hematopoietic stem cell transplantation, which warrants the needs for long-term follow-up. Immune-mediated CMV vasculitis could be an isolated manifestation in patients with a minimal immune deviation and may only be found on fundus fluorescein angiography, which emphasizes the importance of fundus fluorescein angiography on a regular basis during follow-up.

Cytomegalovirus retinitis following dexamethasone intravitreal implant

Purpose

To describe a case of Cytomegalovirus (CMV) Retinitis in an immunocompetent patient following Dexamethasone Intravitreal Implant (DII).

Observations

Retrospective chart review of a single patient. An 80-year-old immunocompetent male presented with floaters in his left eye 10 weeks after his DII. He was noted to have a visual acuity of 20/1200 in his left eye and a panuveitis with CMV retinitis. The patient underwent a vitreous biopsy and given immediate intravitreal foscarnet and an ongoing management regimen of oral valganciclovir for two months. His vision improved to 20/200 and his CMV retinitis resolved.

Conclusion and Importance

DII can trigger CMV retinitis in immunocompetent patients.

Advances in the Diagnosis and Management of Acute Retinal Necrosis

Acute retinal necrosis (ARN) is a devastating syndrome characterized by panuveitis, retinal necrosis, and a high rate of retinal detachment that may result in poor visual outcomes if not promptly diagnosed and treated. ARN is most commonly caused by viruses with the herpesvirus family. Etiologies include varicella-zoster virus, herpes simplex virus, and cytomegalovirus, and may be promptly diagnosed by polymerase chain reaction testing of aqueous or vitreous fluid. The true incidence of ARN is not known due to its rarity; as a result, clinical treatment is often guided by retrospective case series, case reports, and expert opinion. Standard of care has evolved over time but currently includes a combination of systemic and intravitreal antiviral in conjunction with topical or oral steroids and surgical therapy as needed. Combination therapy may reduce the rate of severe vision loss and increase the rate of visual acuity gain, although further studies are needed in this area. In particular for patients with mild to moderate disease, combination therapy may reduce the rate of retinal detachment. Adjunctive therapies including oral corticosteroid and prophylactic laser barricade are incompletely studied, but corticosteroid in particular, may reduce inflammation, which also is involved in the severe disease pathogenesis observed in ARN. This review discusses the advances in diagnosis and treatment of ARN, including management with combination antiviral medication and surgical interventions.

Intravitreal Dexamethasone Implant as a Sustained Release Drug Delivery Device for the Treatment of Ocular Diseases: A Comprehensive Review of the Literature

Drug delivery into the vitreous chamber remains a great challenge in the pharmaceutical industry due to the complex anatomy and physiology of the eye. Intravitreal injection is the mainstream route of drug administration to the posterior segment of the eye. The purpose of this review is to assess the current literature about the widening use of the intravitreal 0.7 mg dexamethasone (Dex) implant, and to provide a comprehensive collection of all the ocular disorders that benefit from Dex administration. Although anti-vascular endothelial growth-factors (VEGFs) have been largely indicated as a first-choice level, the Dex implant represents an important treatment option, especially in selected cases, such as vitrectomized eyes or patients in whom anti-VEGF failed or are contraindicated. In this article, the safety profile as well as the list of the possible complications related to intravitreal Dex injection are also discussed.

Acute retinal necrosis following dexamethasone intravitreal implant (Ozurdex®) administration in an immunocompetent adult with a history of HSV encephalitis: a case report

Background

Dexamethasone intravitreal implants (0.7 mg) (Ozurdex®, Allergan Inc., Madison, NJ) are FDA approved for managing macular oedema (ME) of retinal vein occlusion (RVO). The major complications associated with intravitreal Ozurdex® implant include increased intraocular pressure and cataract progression. In regard to the occurrence of retinal complications, we report an unusual intravitreal Ozurdex® implantation-related acute retinal necrosis (ARN).

Case presentation

A 45-year-old immunocompetent woman with a history of encephalitis presented with photophobia, redness, floaters, and rapidly decreased vision in her left eye. Three and six months ago, she received two doses of intravitreal Ozurdex® implant for ME of RVO. Clinical evaluation, including slit-lamp biomicroscopy, retinal photography, and fluorescein angiography, revealed anterior chamber cells, granulomatous keratic precipitates, cells in the vitreous, optic disc oedema, occlusive retinal vasculitis, scattered retinal haemorrhages, one quadrant of peripheral white areas with retinal necrosis, optic disc and vessels fluorescein staining, and retinal nonperfusion zones. All the above clinical manifestations showed an ARN. Herpes simplex virus was detected in the aqueous and vitreous humour by quantitative polymerase chain reaction testing. Intravenous acyclovir 500 mg tid for 7 days followed by oral valcyclovir was immediately performed for ARN. At 4 months, the patient’s condition improved without retinal detachment, and the best-corrected visual acuity remained stable at 0.3.

Conclusions

ARN might represent a risk of Ozurdex® administration.

RETINAL FINDINGS IN PRESUMED INFECTIOUS POSTERIOR UVEITIS AND CORRELATION WITH POLYMERASE CHAIN REACTION RESULTS

PURPOSE

To correlate demographics, retinal lesion characteristics, and host immune status with the pathogen found on polymerase chain reaction analysis of aqueous fluid in patients with suspected infectious posterior uveitis.

METHODS

Medical records of patients who underwent anterior chamber paracentesis for suspected infectious posterior uveitis and had retinal photographs between 2014 and 2016 at a single institution were reviewed. Data collection included demographics, clinical appearance of the lesions, and polymerase chain reaction results. Fundus photographs were evaluated by two masked observers for the clinical features of the retinitis.

RESULTS

Twenty-eight patients were included in the study. There was substantial to almost perfect agreement on retinitis location (κ = 0.67) and number (κ = 0.76) between the masked photograph graders. Polymerase chain reaction results were positive for herpes simplex virus or varicella zoster virus in 43%, cytomegalovirus in 11%, and toxoplasmosis in 3%; 43% had negative polymerase chain reaction results. Detection of herpes simplex virus or varicella zoster virus on polymerase chain reaction of the aqueous was associated with paucifocal lesions (82%, P = 0.021) and lesions involving the peripheral retina (91%, P = 0.023), consistent with the diagnosis of acute retinal necrosis.

CONCLUSION

These data suggest that the diagnosis of acute retinal necrosis can be reasonably inferred on clinical examination, providing a guide for initial empiric therapy.

Corticosteroids for Diabetic Macular Edema

Diabetic macular edema (DME) is a chronic condition with a multifactorial pathogenesis. Vascular endothelial growth factor (VEGF) and several inflammatory mediators are upregulated in eyes with DME. VEGF inhibitors and corticosteroids have all been used successfully in the management of DME. Currently available corticosteroids include triamcinolone acetonide (TA), the dexamethasone (DEX) intravitreal implant, and the fluocinolone acetonide (FA) intravitreal implant. The response to treatment can vary substantially with each treatment modality. Some cases of DME are VEGF driven, and in others, inflammation plays a key role. Chronicity appears to favor corticosteroid treatment. There are no clear guidelines to guide switching from an anti-VEGF to a corticosteroid. Combination therapy of an anti-VEGF drug and a corticosteroid does not appear to provide additional benefit over monotherapy with either drug. The main advantage of corticosteroids over VEGF inhibitors is their longer duration of action. Vitrectomy does not affect the pharmacokinetics of the corticosteroid implants. Common adverse events of corticosteroids include cataract formation, cataract progression, and ocular hypertension. TA may cause a sterile endophthalmitis and pseudoendophthalmitis. Migration of the intravitreal DEX and FA implants into the anterior chamber can be problematic. Because of their less favorable safety profile, corticosteroids are generally used as a second-line treatment for DME. Advantages of using an intravitreal corticosteroid implant include the reduction of treatment burden and predictable pharmacokinetics even in vitrectomized eyes. Pseudophakic eyes, previously vitrectomized eyes and eyes with long-standing DME, particularly of patients who have difficulty in maintaining a monthly appointment, may benefit from primary treatment with a corticosteroid intravitreal implant.

Bilateral acute necrotizing retinitis due to cytomegalovirus infection in an infant: Challenging case report

Purpose

To report a case of bilateral acute necrotising retinitis due to cytomegalovirus infection (CMV) in an Asian Indian infant.

Observations

An Asian Indian infant born with a birth weight of 1000 g at 26 week of gestation acquired cytomegalovirus infection from repeated blood transfusion for anemia. During the routine course of ROP screening, both eyes were detected with Type 1 ROP (stage 3 in zone 1 with plus disease) and treated with laser photoablation at 39 + 2 weeks post menstrual age. The disease responded to the laser and showed signs of regression. Four weeks after laser therapy (PMA 43 + 3 weeks), both eyes presented with vitritis, inferior vitreous condensation and white lesions in the lower nasal retina and temporal retina overlying the lasered retinal bed associated with white fluffy hemorrhagic lesions resembling necrotising retinitis. As the infant was seropositive for CMV earlier, Necrotising retinitis due to CMV was suspected. The CMV DNA was repeated and was detected in serum. Infant was treated with anti-CMV medication (oral valgancyclovir) for six weeks. The retinal lesions resolved completely.

Conclusion and Importance

Bilateral acute necrotising retinitis may present in an infant on post lasered retina as early as 16 weeks after birth. CMV may also present as acute necrotising retinitis in unusual cases therefore high index of suspicion and early management can result in a successful outcome.

[Pharmacological treatment strategies and surgical options for uveitis]

BACKGROUND

Modern treatment of uveitis aims at a complete control of inflammatory activity, preservation of visual function and the prevention of secondary organ damage as a consequence of the underlying inflammatory disease and its treatment.

OBJECTIVE

This article gives an update about the strategies of pharmacological and surgical options for uveitis.

MATERIAL AND METHODS

The outcomes reported here are based on a PubMed search using the terms <"uveitis" AND "therapy"> and <"uveitis" AND "surgery" OR "surgical treatment">. All prospective studies and case series with more than 20 cases as well as review articles from the last 5 years along with cited cross-references were evaluated.

RESULTS

Local and systemic corticosteroids form the foundation of treatment after exclusion of an infectious etiology. If uveitis activity is not controlled within 6 weeks or if the daily corticosteroid dosage is unacceptably high, a treatment escalation using immunomodulatory drugs is required. If a complete control of inflammatory activity is not achieved, in a third phase treatment is supplemented by antibody-based treatment or cytokines, so-called biologics, with the aim of complete long-term freedom from disease without local or systemic steroid treatment. This target is achieved in 65-80% and guarantees long-term functional stability and anatomical integrity. Early treatment escalation in cases of persisting or recurrent activity as a rule prevents new secondary organ damage. Surgical options are utilized for diagnostic purposes, the administration of intravitreal drugs and for treatment of secondary complications.

CONCLUSION

Just like the majority of immunological diseases, uveitis is a chronic disease requiring long-term and possibly lifelong treatment and remission (absence of inflammation without treatment) is achieved in only <20%. Surgical interventions can be performed with a good prognosis, if the optic nerve head and macula are not involved. They have a substantially lower complication rate when freedom from symptoms exists preoperatively for at least 3 months.

Macular cytomegalovirus retinitis following dexamethasone intravitreal implant combined with phacoemulsification

A 60-year-old diabetic patient, who had undergone a renal transplant 2 years earlier, presented with sudden decrease in vision in his left eye (LE). He had undergone phacoemulsification combined with intravitreal dexamethasone implant injection in his LE 2 months earlier, for coexistent cataract and diabetic macular edema. Examination revealed necrotizing retinitis with hemorrhages in the macula. A diagnosis of cytomegalovirus retinitis was made, which was confirmed on vitreous polymerase chain reaction. Intravitreal and systemic ganciclovir led to the resolution of retinitis and improvement of visual acuity over a follow-up of 9 months.